Progress toward Health System Readiness for Genome-Based Testing in Canada.

(1) Background: Genomic medicine harbors the real potential to improve the health and healthcare journey of patients, care provider experiences, and improve the health system efficiency-even reducing healthcare costs. There is expected to be an exponential growth in medically necessary new genome-based tests and test approaches in the coming years. Testing can also create scientific research and commercial opportunities beyond healthcare decision making. The purpose of this research is to generate a better understanding of Canada's state of readiness for genomic medicine, and to provide some insights for other healthcare systems. (2) Methods: A mixed-methods approach of a review of the literature and key informant interviews with a purposive sample of experts was used. The health system readiness was assessed using a previously published set of conditions. (3) Results: Canada has created some of the established conditions, but further action needs to be taken to improve the state of readiness for genome-based medicine. The important gaps to be filled are the need for linked information systems and data integration; evaluative processes that are timely and transparent; navigational tools for care providers; dedicated funding to facilitate rapid onboarding and support test development and proficiency testing; and broader engagement with innovation stakeholders beyond care providers and patients. These findings highlight the role of the organizational context, social influence, and other factors that are known to affect the diffusion of innovation within health systems.

Consolidated principles for screening based on a systematic review and consensus process.

BACKGROUND: In 1968, Wilson and Jungner published 10 principles of screening that often represent the de facto starting point for screening decisions today; 50 years on, are these principles still the right ones? Our objectives were to review published work that presents principles for population-based screening decisions since Wilson and Jungner's seminal publication, and to conduct a Delphi consensus process to assess the review results. METHODS: We conducted a systematic review and modified Delphi consensus process. We searched multiple databases for articles published in English in 1968 or later that were intended to guide population-based screening decisions, described development and modification of principles, and presented principles as a set or list. Identified sets were compared for basic characteristics (e.g., number, categorization), a citation analysis was conducted, and principles were iteratively synthesized and consolidated into categories to assess evolution. Participants in the consensus process assessed the level of agreement with the importance and interpretability of the consolidated screening principles. RESULTS: We identified 41 sets and 367 unique principles. Each unique principle was coded to 12 consolidated decision principles that were further categorized as disease/condition, test/intervention or program/system principles. Program or system issues were the focus of 3 of Wilson and Jungner's 10 principles, but comprised almost half of all unique principles identified in the review. The 12 consolidated principles were assessed through 2 rounds of the consensus process, leading to specific refinements to improve their relevance and interpretability. No gaps or missing principles were identified. INTERPRETATION: Wilson and Jungner's principles are remarkably enduring, but increasingly reflect a truncated version of contemporary thinking on screening that does not fully capture subsequent focus on program or system principles. Ultimately, this review and consensus process provides a comprehensive and iterative modernization of guidance to inform population-based screening decisions.

Why equity in health and in access to health care are elusive: Insights from Canada and South Africa.

Health and access to health care vary strikingly across the globe, and debates about this have been pervasive and controversial. Some comparative data in Canada and South Africa illustrate the complexity of achieving greater equity anywhere, even in a wealthy country like Canada. Potential bi-directional lessons relevant both to local and global public health are identified. Both countries should consider the implications of lost opportunity costs associated with lack of explicit resource allocation policies. While National Health Insurance is attractive politically, Canada's example cannot be fully emulated in South Africa. Short- and medium-term attempts to improve equity in middle-income countries should focus on equitable access to insurance to cover primary health care and on making more use of nurse practitioners and community health workers. In the longer-term, attention is needed to the economic and political power structures that influence health and health care and that ignore the social and societal determinants of sustainable good health locally and globally. This long-term vision of health is needed globally to achieve improvements in individual and population health in a century characterised by limits to economic growth, widening disparities, continuing conflict and migration on a large scale and multiple adverse impacts of climate change.

Building the Ontario Surgical Oncology Program.

From the 1940s onward the establishment of an increasing number of cancer centres in Ontario concentrated predominantly on radiation and systemic therapy. Increasing attention to the organization of cancer surgery services in Ontario over the last 3 decades through measures led by Cancer Care Ontario has resulted in building a progressive provincial and regional surgical oncology network. These networks are rooted in leadership mobilization and have used quality data and best evidence to promote the elaboration of communities of practice to achieve better outcomes. This article briefly chronicles this journey and points to areas of progress.

Costs, affordability, and feasibility of an essential package of cancer control interventions in low-income and middle-income countries: key messages from Disease Control Priorities, 3rd edition.

Investments in cancer control--prevention, detection, diagnosis, surgery, other treatment, and palliative care--are increasingly needed in low-income and particularly in middle-income countries, where most of the world's cancer deaths occur without treatment or palliation. To help countries expand locally appropriate services, Cancer (the third volume of nine in Disease Control Priorities, 3rd edition) developed an essential package of potentially cost-effective measures for countries to consider and adapt. Interventions included in the package are: prevention of tobacco-related cancer and virus-related liver and cervical cancers; diagnosis and treatment of early breast cancer, cervical cancer, and selected childhood cancers; and widespread availability of palliative care, including opioids. These interventions would cost an additional US$20 billion per year worldwide, constituting 3% of total public spending on health in low-income and middle-income countries. With implementation of an appropriately tailored package, most countries could substantially reduce suffering and premature death from cancer before 2030, with even greater improvements in later decades.

Using clinical governance levers to support change in a cancer care reform.

PURPOSE: Introducing change is a difficult issue facing all health care systems. The use of various clinical governance levers can facilitate change in health care systems. The purpose of this paper is to define clinical governance levers, and to illustrate their use in a large-scale transformation. DESIGN/METHODOLOGY/APPROACH: The empirical analysis deals with the in-depth study of a specific case, which is the organizational model for Ontario's cancer sector. The authors used a qualitative research strategy and drew the data from three sources: semi-structured interviews, analysis of documents, and non-participative observations. FINDINGS: From the results, the authors identified three phases and several steps in the reform of cancer services in this province. The authors conclude that a combination of clinical governance levers was used to transform the system. These levers operated at different levels of the system to meet the targeted objectives. PRACTICAL IMPLICATIONS: To exercise clinical governance, managers need to acquire new competencies. Mobilizing clinical governance levers requires in-depth understanding of the role and scope of clinical governance levers. ORIGINALITY/VALUE: This study provides a better understanding of clinical governance levers. Clinical governance levers are used to implement an organizational environment that is conducive to developing clinical practice, as well as to act directly on practices to improve quality of care.

Improving quality and performance in Ontario's cancer services: lessons for constructing a learning healthcare system.

Cancer Care Ontario as a provincial agency has undergone a significant transformation in the last 10 years. This paper documents a predictable crisis of radiotherapy capacity at the turn of the millennium, creating an imperative for transformative change. This transformation occurred included a divestment of existing cancer centers to large local host hospitals while retaining service obligations through a financial, quality and performance contract. The paper documents the simultaneous introduction of quality and access measures and the creation of a continuously evolving improvement panel of metrics which underpin the performance of local centers and population-wide reporting of Cancer Control. The recent successful expansion to include renal services is referenced.

Accountability in the ontario cancer services system: a qualitative study of system leaders' perspectives.

Cancer Care Ontario (CCO), the provincial cancer agency, operates under a model of accountable governance that has been hailed as exemplary. We explored cancer system leaders' views on the balance and perceived efficacy of approaches to accountability in this context. Semi-structured interviews were conducted with 19 participants (MOHLTC=5, CCO=14). Adopting a qualitative descriptive approach, we coded data for four policy instruments used in approaches to accountability. Financial incentives are a key lever used by both parties to effect change. Cancer-specific regulations were somewhat weak, but agency-wide directives were a necessary nuisance that had great force. The effect of public reporting on mobilizing consumer sovereignty was questioned; however, transparency for its own sake was highly valued. Professionalism and stewardship, with an emphasis on trust-based partnerships and clinical engagement, were critical to CCO's success. These approaches were seen to work together, but what made each have force was reliance on professionalism and stewardship.

Real world costs and cost-effectiveness of Rituximab for diffuse large B-cell lymphoma patients: a population-based analysis.

BACKGROUND: Current treatment of diffuse-large-B-cell lymphoma (DLBCL) includes rituximab, an expensive drug, combined with cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP) chemotherapy. Economic models have predicted rituximab plus CHOP (RCHOP) to be a cost-effective alternative to CHOP alone as first-line treatment of DLBCL, but it remains unclear what its real-world costs and cost-effectiveness are in routine clinical practice. METHODS: We performed a population-based retrospective cohort study from 1997 to 2007, using linked administrative databases in Ontario, Canada, to evaluate the costs and cost-effectiveness of RCHOP compared to CHOP alone. A historical control cohort (n = 1,099) with DLBCL who received CHOP before rituximab approval was hard-matched on age and treatment intensity and then propensity-score matched on sex, comorbidity, and histology to 1,099 RCHOP patients. All costs and outcomes were adjusted for censoring using the inverse probability weighting method. The main outcome measure was incremental cost per life-year gained (LYG). RESULTS: Rituximab was associated with a life expectancy increase of 3.2 months over 5 years at an additional cost of $16,298, corresponding to an incremental cost-effectiveness ratio of $61,984 (95% CI $34,087-$135,890) per LYG. The probability of being cost-effective was 90% if the willingness-to-pay threshold was $100,000/LYG. The cost-effectiveness ratio was most favourable for patients less than 60 years old ($31,800/LYG) but increased to $80,600/LYG for patients 60-79 years old and $110,100/LYG for patients ≥ 80 years old. We found that post-market survival benefits of rituximab are similar to or lower than those reported in clinical trials, while the costs, incremental costs and cost-effectiveness ratios are higher than in published economic models and differ by age. CONCLUSIONS: Our results showed that the addition of rituximab to standard CHOP chemotherapy was associated with improvement in survival but at a higher cost, and was potentially cost-effective by standard thresholds for patients <60 years old. However, cost-effectiveness decreased significantly with age, suggesting that rituximab may be not as economically attractive in the very elderly on average. This has important clinical implications regarding age-related use and funding decisions on this drug.

Responsibility for Canada's healthcare quality agenda: interviews with Canadian health leaders.

Canadian healthcare is under increased scrutiny to improve quality and performance, and for good reason. The proliferation of provincial-level quality councils underscores the urgency to establish an aligned national quality agenda. Patient safety has long been held as a critical element of a high-quality healthcare system; with the inexorable growth in spending, efficiency has more recently been introduced. Efficiency and quality are both factors in Ontario's Excellent Care for All legislation introduced in June of 2010, and Quebec's l'Institut national d'excellence en santé et en services sociaux (INESSS) arising from the Castonguay report. These associations of quality and efficiency are also echoed in the US, Australian and UK public debates. The development of a quality agenda has concurrently precipitated discussion regarding responsibility for quality, particularly but not exclusively with the emergence of quality issues in the technical and interpretive pathology arena. The discussion and debate on responsibility have become preoccupations at the national, provincial, institutional and individual profession levels.

Access to cancer drugs in Canada: looking beyond coverage decisions.

OBJECTIVE: To examine variation in patients' access to a set of cancer drugs through publicly funded provincial drug programs. DATA SOURCES/STUDY DESIGN: We surveyed provincial drug program managers about their highest-expenditure intravenous and oral cancer drugs. We then investigated whether the same cancer drugs account for the highest expenditures across the provincial programs. We also compared the rates at which these drugs are accessed through these programs. PRINCIPAL FINDINGS: While there is moderate consistency in the selection of cancer drugs that account for the highest provincial expenditures, considerable differences were found in the rates at which some drugs are accessed across provincial programs. CONCLUSIONS: The study demonstrates the existence of interprovincial variation in publicly funded access to cancer drugs even after these drugs have been approved for public coverage.

Breast cancer screening program in Canada: successes and challenges.

This paper describes breast screening program development in Canada and the current status of screening in Canada. Programs have been implemented in most of Canada, beginning in the late 1980's. Certain components are common to all the programs, but others, such as personal invitation letters for recruitment and clinical breast examination vary across the country. Key successes in organized breast screening in Canada include the development of a comprehensive set of screening performance indicators, which are reported on regularly, and the downward trend in mortality rates observed over the past 20 years. Challenges include the continued prevalence of opportunistic screening; the need to better manage follow-up; dealing with changing evidence; and supporting informed decision-making about screening. Approaches to breast screening are dependent on the health care services available in countries, but regardless of the approach, good evaluation is necessary.

Fecal occult blood testing: people in Ontario are unaware of it and not ready for it.

OBJECTIVE: To determine factors that influence awareness of, and readiness to undergo, fecal occult blood testing (FOBT) for colorectal cancer (CRC) screening. DESIGN: Validated survey designed to ascertain respondents' stages of decision making regarding CRC screening using FOBT. SETTING: Ontario. PARTICIPANTS: A total of 1013 people 50 years old and older drawn from all regions of the province using a random-digit dialing telephone protocol. MAIN OUTCOME MEASURES: Awareness of FOBT and readiness to undergo it for screening for CRC. RESULTS: Response rate was 69%. Results indicated that 54% of women and 45% of men had "heard of" FOBT, and 26% of women and 17% of men had heard of it but were still "not considering" FOBT screening. Only 17% of all respondents had "decided to have" FOBT screening. Demographic factors associated with having heard of FOBT were female sex, completion of college or higher education, and being married or living as married. Demographic factors associated with active consideration of FOBT among those who reported awareness of it were male sex and being married or living as married. CONCLUSION: Many people seemed uninformed about FOBT and not ready to undertake this type of screening. Results of this survey could help guide strategies and develop programs to make eligible people aware of CRC screening using FOBT and to motivate them to undergo testing.

Measuring Integration of Cancer Services to Support Performance Improvement: The CSI Survey.

OBJECTIVE: To develop a measure of cancer services integration (CSI) that can inform clinical and administrative decision-makers in their efforts to monitor and improve cancer system performance. METHODS: We employed a systematic approach to measurement development, including review of existing cancer/health services integration measures, key-informant interviews and focus groups with cancer system leaders. The research team constructed a Web-based survey that was field- and pilot-tested, refined and then formally conducted on a sample of cancer care providers and administrators in Ontario, Canada. We then conducted exploratory factor analysis to identify key dimensions of CSI. RESULTS: A total of 1,769 physicians, other clinicians and administrators participated in the survey, responding to a 67-item questionnaire. The exploratory factor analysis identified 12 factors that were linked to three broader dimensions: clinical, functional and vertical system integration. CONCLUSIONS: The CSI Survey provides important insights on a range of typically unmeasured aspects of the coordination and integration of cancer services, representing a new tool to inform performance improvement efforts.

Breast cancer screening program in canada: successes and challenges / Programas de detección temprana de cáncer de mama en canadá: avances y obstáculos

This paper describes breast screening program development in Canada and the current status of screening in Canada. Programs have been implemented in most of Canada, beginning in the late 1980's. Certain components are common to all the programs, but others, such as personal invitation letters for recruitment and clinical breast examination vary across the country. Key successes in organized breast screening in Canada include the development of a comprehensive set of screening performance indicators, which are reported on regularly, and the downward trend in mortality rates observed over the past 20 years. Challenges include the continued prevalence of opportunistic screening; the need to better manage follow-up; dealing with changing evidence; and supporting informed decision-making about screening. Approaches to breast screening are dependent on the health care services available in countries, but regardless of the approach, good evaluation is necessary.

Este artículo describe el desarrollo de la detección temprana de cáncer de mama en Canadá así como la situación actual de los programas de detección de cáncer en el mismo país. En su gran mayoría, estos programas de detección han sido implementados desde comienzos de los años ochenta. Algunos elementos de estos programas representan denominadores comunes en todos ellos. Sin embargo existen otros elementos -tales como invitaciones personales para reclutamiento y exámenes clínicos de mama, que difieren dependiendo de cada jurisdicción. Algunos de los avances en los programas organizados de detección temprana de cáncer de mama en Canadá incluyen la existencia de indicadores de evaluación de desempeño, sobre los cuales se reporta de forma regular. En base a estos indicadores se puede observar una tendencia descendente en los índices de mortalidad en los últimos 20 años. Algunas de las dificultades incluyen la persistencia de detección oportunística, la necesidad de gerenciar el efectivo seguimiento de pacientes, gerenciar el constante cambio de evidencia, así como el proveer asistencia en la toma de decisiones relacionadas a la detección temprana de cáncer. Las prácticas focalizadas en mejorar la detección temprana de cáncer dependen de los servicios de salud existentes en cada país. Sin embargo e independientemente de la orientación utilizada, la necesidad de evaluar el desempeño de los programas es un elemento vital.

Shifting clinical accountability and the pursuit of quality: aligning clinical and administrative approaches.

This paper presents a narrative review of the literature on clinical accountability, and draws particularly on England's experience establishing "clinical governance" as a base to examine the establishment of a clinical accountability framework for cancer services in Ontario. The review suggests that clinical governance and accountability approaches that actively mesh clinical and administrative approaches at both system and local levels are more likely to be effective in improving quality of care.

Response audit of an Internet survey of health care providers and administrators: implications for determination of response rates.

BACKGROUND: Internet survey modalities often compare unfavorably with traditional survey modalities, particularly with respect to response rates. Response to Internet surveys can be affected by the distribution options and response/collection features employed as well as the existence of automated (out-of-office) replies, automated forwarding, server rejection, and organizational or personal spam filters. However, Internet surveys also provide unparalleled opportunities to track study subjects and examine many of the factors influencing the determination of response rates. Tracking data available for Internet surveys provide detailed information and immediate feedback on a significant component of response that other survey modalities cannot match. This paper presents a response audit of a large Internet survey of more than 5000 cancer care providers and administrators in Ontario, Canada. OBJECTIVE: Building upon the CHEcklist for Reporting Results of Internet E-Surveys (CHERRIES), the main objectives of the paper are to (a) assess the impact of a range of factors on the determination of response rates for Internet surveys and (b) recommend steps for improving published descriptions of Internet survey methods. METHODS: We audited the survey response data, analyzing the factors that affected the numerator and denominator in the ultimate determination of response. We also conducted a sensitivity analysis to account for the inherent uncertainty associated with the impact of some of the factors on the response rates. RESULTS: The survey was initially sent out to 5636 health care providers and administrators. The determination of the numerator was influenced by duplicate/unattached responses and response completeness. The numerator varied from a maximum of 2031 crude (unadjusted) responses to 1849 unique views, 1769 participants, and 1616 complete responses. The determination of the denominator was influenced by forwarding of the invitation email to unknown individuals, server rejections, automated replies, spam filters, and 'opt out' options. Based on these factors, the denominator varied from a minimum of 5106 to a maximum of 5922. Considering the different assumptions for the numerator and the denominator, the sensitivity analysis resulted in a 12.5% variation in the response rate (from minimum of 27.3% to maximum of 39.8%) with a best estimate of 32.8%. CONCLUSIONS: Depending on how the numerator and denominator are chosen, the resulting response rates can vary widely. The CHERRIES statement was an important advance in identifying key characteristics of Internet surveys that can influence response rates. This response audit suggests the need to further clarify some of these factors when reporting on Internet surveys for health care providers and administrators, particularly when using commercially available Internet survey packages for specified, rather than convenience, samples.